In history of exercise physiology is often forgotten that Susruta of
ancient India was the first physician to prescribe physical activity for
health reasons. He promoted dietary changes and daily exercise of moderate
intensity such as brisk walking to minimize the consequences of diabetes
and obesity (1). Today, elderly people are very likely to benefit even
from simple, full-body exercise...
In history of exercise physiology is often forgotten that Susruta of
ancient India was the first physician to prescribe physical activity for
health reasons. He promoted dietary changes and daily exercise of moderate
intensity such as brisk walking to minimize the consequences of diabetes
and obesity (1). Today, elderly people are very likely to benefit even
from simple, full-body exercises, such as rising from a chair and sitting
back down again (10 repetitions, two to three times a day).
1. Tipton CM. Susruta of India, an unrecognized contributor to the
history of exercise physiology. J Appl Physiol 2008;104:1553-6.
The paper by Plum et al. (1) prompted us to verify how fourth year
medical students performed in choosing the initial dose and route of
administration of adrenaline in the treatment of adult anaphylaxis. The
question was one of the 20 they had to answer by blackening the correct
box (C for this specific question) to pass the Clinical Immunology (CI)
exam. Many (approximately two-thirds) of the 192 students who resp...
The paper by Plum et al. (1) prompted us to verify how fourth year
medical students performed in choosing the initial dose and route of
administration of adrenaline in the treatment of adult anaphylaxis. The
question was one of the 20 they had to answer by blackening the correct
box (C for this specific question) to pass the Clinical Immunology (CI)
exam. Many (approximately two-thirds) of the 192 students who responded to
the multiple choice question had attended the 16 hour CI course, which
included one and a half hour lecture on the causes, clinical
presentation, diagnostic criteria, differential diagnosis and management
of anaphylaxis according to the WAO guidelines (2) only about one month
before .
The multiple choice question was A. 500 mg IM, B. 500 mg IV, C. 500
micrograms IM, D. 500 micrograms IV, E. 500 micrograms SC.
Only 45% chose the correct dose and route. 62 out of 192 (32%) chose the
wrong dose (500 mg) and the correct route (IM) while 13% (25 out of 192)
the correct dose (500 micrograms)and the wrong route (either IV or SC).
Eighteen medical students (9%) would have inappropriately given 500 mg IV
to their anaphylaxis patients.
Our medical students did only a little better than Pump et al'. junior
doctors (45% vs 34% chose the correct route and dose, chi square p=0.09)
but still only about half of those who had supposedly been lectured just
one month before undertaking the test were aware of the correct dose and
route of adrenaline for emergency management of anaphylaxis.
Reference
1.Plumb B et al. Correct recognition and management of anaphylaxis:
not much change over a decade. Postgrad Med J 2015;91:3-7
doi:10.1136/postgradmedj-2013-132181.
2. Simons FER et al. World Allergy Organizationguidelines for the
assessment and management of anaphylaxis.WAO Journal 2011;13-37.
This article points out the well documented fact that increased
physical activity has clear-cut protective effect from all cause
mortality(1). Developing countries like India are also acknowledging such
facts and are issuing guidelines for the same so as to promote health care
of elderly even at primary health care level(2).
With development and prosperity the average individual age is
increasin...
This article points out the well documented fact that increased
physical activity has clear-cut protective effect from all cause
mortality(1). Developing countries like India are also acknowledging such
facts and are issuing guidelines for the same so as to promote health care
of elderly even at primary health care level(2).
With development and prosperity the average individual age is
increasing which is attracting focus of governments and policy makers
towards growing need to cater to such population. The root cause of major
physical impairment in old age is physical inactivity and its
consequences, this fact need to be projected in a clear and concrete way
in the midst of general population specially the elderly and their
families.
The physician, individual concerned and community all should work in
synchronization towards promoting health and vitality to the elderly.
There needs to be greater involvement of elderly into accepting increasing
bodily movements as a part of life. Another area of concern will be ways
to protract such activity and devote greater manpower and political will
towards this often neglected but inevitable phase of life.
References :
1. Ueshima K, Ishikawa-Takata K, Yorifuji T, et al Physical
activity and mortality risk in the Japanese elderly. A cohort study. Am J
Prev Med 2010;38:410-18.
2. www.mohfw.nic.in/WriteReadData/l892s/NPHCE.pdf Ministery of
Health and Family Welfare, Government Of India, New Delhi, India.
11/11/2013.
The increasing numbers of frail elderly patients certainly poses a
challenge for all parts of the healthcare landscape within the UK and
beyond. Whilst organisational change and modifications to where, when and
how we deliver care is important this must be underpinned by appropriate
education for doctors and allied healthcare professionals.
Much of this needs to be aimed at more junior staff, especially
medical...
The increasing numbers of frail elderly patients certainly poses a
challenge for all parts of the healthcare landscape within the UK and
beyond. Whilst organisational change and modifications to where, when and
how we deliver care is important this must be underpinned by appropriate
education for doctors and allied healthcare professionals.
Much of this needs to be aimed at more junior staff, especially
medical students and junior doctors. Elderly care medicine has been
undervalued for too long and the complexities of older people have been
underestimated. Education therefore needs to be focussed on two main
areas:
1. An ability to understand complex medical conditions, the
interactions that these conditions have with each other and the
medications that can improve and worsen these problems. This must be
learnt in the context of the multi-disciplinary team and understand the
complex psycho-social dimensions that exist within the ageing community.
2. An understanding that over medicalisation of the health needs of
older people can be detrimental to both physical and psychological care,
in particular the understanding that just because we can investigate and
treat problems doesn't mean that we should. These decisions are complex
and should be made in conjunction with patients, their families and
independant advocates if patients lack capacity and family.
Changes to the care of older people must be made in a sustainable and
holistic way which have education as the foundation to ensure
modifications are successful.
Conflict of Interest:
Academic Clinical Fellow in Medical Education at Plymouth University
Predicting prognosis in this older group of patients is complex due
to their highly variable health status, driven by their fundamentally
different prognosis to younger patients. We have published two recent
pieces on this theme, showing that firstly though there was an incremental
reduction in the use of evidence-based therapies for ACS (acute coronary
syndrome) with older age and that better survival was associated with...
Predicting prognosis in this older group of patients is complex due
to their highly variable health status, driven by their fundamentally
different prognosis to younger patients. We have published two recent
pieces on this theme, showing that firstly though there was an incremental
reduction in the use of evidence-based therapies for ACS (acute coronary
syndrome) with older age and that better survival was associated with
intensive management at all ages, this benefit was attenuated the older
the patient.(1) Secondly, higher troponin levels are associated with
increasing risk of mortality, but we found very high mortality rates in
older patients even at the lowest troponin values. There was an
attenuation of the prognostic value of troponins in older age and thus,
the prognostic value of troponins depends on patient age in ACS -
essentially, age is the biggest prognostic marker, and arguably markers we
use in younger patients are not as relevant in older patients.(2) Current
risk scores to guide aggressive management of coronary disease in the
older person perform poorly, over-estimating mortality and ignoring
morbidity, perhaps of more relevance to this age group.(3) In a population
of older adults, adjustment for 27 biological risk factors including co-
morbidity, social status, lifestyle and disease factors, cognition and
frailty substantially reduced the association between chronological age
and 5-year mortality (ages 80-84 years: unadjusted relative risk, 4.1;
adjusted relative risk, 1.7).(4)
As outcomes are influenced by both age and co-morbidity, is the under
-treatment of older people with ACS relative to younger patients thus
'appropriate'? Evidence suggests that risks associated with more intensive
management in older people may be related more to their greater co-
morbidity than age alone(5) and thus chronological age alone may not be
the best measure by which to plan clinical management in older people.
Trials also tend to focus on hard outcomes and also rarely take into
account wider prognostic measures such as disability, repeated
hospitalisation and return to independent living that are more relevant in
older people. Others have also written that sometimes following exacting
clincial guidelines that lead to more treatment may not be in the best
interests of the older patient.(6)
The ideal pathway in the older patient for example with an ACS should
not assume early intervention with revascularisation is the optimum
strategy (as is usually the case in the younger patient) but should be a
more holistic management strategy based upon thorough comprehensive
geriatric assessment. Frailty,(7) functional status, and social aspects of
care in the elderly are rarely included as clinical parameters (read wider
prognostic markers) in decisions pertaining to future care. Furthermore,
outcomes beyond survival need assessing, and ones of particular relevance
to the older patient.
1. Zaman MJ, Stirling S, Shepstone L, Ryding A, Flather M, Bachmann
M, et al. The association between older age and receipt of care and
outcomes in patients with acute coronary syndromes: a cohort study of the
Myocardial Ischaemia National Audit Project (MINAP). European Heart
Journal. 2014 March 18, 2014.
2. Myint PK, Kwok CS, Bachmann MO, Stirling S, Shepstone L, Zaman
MJS. Prognostic value of troponins in acute coronary syndrome depends upon
patient age. Heart. 2014 June 26, 2014.
3. Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, et
al. Early and late outcomes of cardiac surgery in octogenarians. Ann
Thorac Surg. 2009 Jan;87(1):71-8.
4. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF,
et al. Risk factors for 5-year mortality in older adults: the
Cardiovascular Health Study. JAMA. 1998 Feb 25;279(8):585-92.
5. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A,
et al. Age, clinical presentation, and outcome of acute coronary syndromes
in the Euroheart acute coronary syndrome survey. Eur Heart J. 2006
Apr;27(7):789-95.
6. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical
practice guidelines and quality of care for older patients with multiple
comorbid diseases: Implications for pay for performance. JAMA. [doi:
10.1001/jama.294.6.716]. 2005;294(6):716-24.
7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J,
et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of
Gerontology Series A: Biological Sciences and Medical Sciences. 2001 March
1, 2001;56(3):M146-M57.
Dear editor:
We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ. The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience on this matter.
We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January and February, 2014.
In all c...
Dear editor:
We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ. The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience on this matter.
We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January and February, 2014.
In all cases the diagnosis of biliary stones was established by an abdominal ultrasound or surgical confirmation.
Patients were interviewed on sex, age, parity, family history of cholelitiasis. Skin fair and the body mass index were determined by our team.
Parity was considered positive when there was at least one born child. Fat was considered as such with a BMI of 25 or more. A family history was considered positive if a first degree relative had been diagnosed or had surgery for cholelithiasis.
A total of 173 patients were included; with an age average of 50,16 +- 14 years and 79.8 % female. The frequency of each of the 6 Fs studied are a)Fertility:95.7% ; b)Female: 97.8% ; c)Forty: 75.1% ; d)Fat: 69.9% ; e)Family History: 46.2%, f) Fair: 4%
(*Fertility: only females ; fat: excluded 69 patients with surgical confirmation)
According to our results, fertility, female gender, age above 40 years and an increased BMI were the 4 Fs that best predicted cholelithiasis. In Peru, and particularly in Callao, where predominant skin phototypes are III, IV and V and fair skin is very rarely found, the F of fair, should be disregarded[2]. Therefore, we agree with the authors that Family History should also be considered as a predictive factor.
Conflict of Interest: None declared
REFERENCES
1. Bass G, Gilani SNS,Walsh TN.Validating the 5Fs mnemonic for cholelithiasis: time
to include family history. Postgrad Med J 2013;89:638-641.
2. Ramos C, Ramos M. Conocimientos, actitudes y practicas en fotoproteccion y fototipo cutaneo en asistentes a una campana preventiva del cancer de piel. Callao-Peru. Febrero 2010.Dermatol Peru 2010;20(3):169-173
When Professor Weller and her colleagues speak of members of the team
being "on the same page"(1) no mention is made of the patient(or the
patient's advocate)(2) being also on the identical page. To facilitate the
inclusion of the patient in the team I have proposed the use of an
abbreviated patient-held health record which essentially documents the
problem list and the corresponding drug list, and this should be updated...
When Professor Weller and her colleagues speak of members of the team
being "on the same page"(1) no mention is made of the patient(or the
patient's advocate)(2) being also on the identical page. To facilitate the
inclusion of the patient in the team I have proposed the use of an
abbreviated patient-held health record which essentially documents the
problem list and the corresponding drug list, and this should be updated
each time the patient attends a healthcare facility(3). So as to mitigate
the risk of inadvertent adverse drug interactions, the community
pharmacist, too, needs to be on the same page as the patient. Accordingly,
each time new medication is prescribed, the patient should be advised to
take his abbreviated patient-held record with him so that he can spell out
to the pharmacist what his current medications are(4).
Finally, in recognition of the potential for the hierarchical structure to
generate "disastrous consequences"(1), patient-related correspondence from
secondary care to primary care must include a copy to the patient so that
the patient can compile his own medical file, which he can then carry with
him to complement the abbreviated patient-held record in the event of an
admission(here or overseas) to a hospital other than his usual hospital.
The patient can also refer to that medical file if he wants to correct
factual inaccuracies which sometimes creep into the correspondence. At a
stroke such measures would create a level playing field between the
patient and the healthcare team, thereby mitigating the risk of disastrous
consequences attributable to the hierarchical system.
References
(1)Weller J., Boyd M., Cumin D
Teams, tribes, and patient safety: overcoming the barriers to effective
teamwork in healthcare
Postgrad Med J 2014;90:1490154
(2)Jolobe OMP
Bridging the communication gap between healthcare providers and patients'
advocates
Brit J Hosp Med 2012;73:654
(3)Jolobe OMP
The abbreviated patient-held health record: bridging the communication gap
Brit J Hosp Med 2012;73:234
(4) Jolobe OMP
Can phrmacists help prevent adverse drug ineractions from newly prescribed
drugd
Br J Hosp Med 2009;70:360
I would like to thank the author on a thoughtful reflection on the
"unconscious mind" and would like to comment on its relevance in modern
medicine especially psychiatry and allied fields.
Understandably concepts like the "drive theory" or "defence
mechanisms" do not lend themselves to critical appraisal in "Evidence-
based Medicine" terms easily but that in it should not detract from their
usefulness in every...
I would like to thank the author on a thoughtful reflection on the
"unconscious mind" and would like to comment on its relevance in modern
medicine especially psychiatry and allied fields.
Understandably concepts like the "drive theory" or "defence
mechanisms" do not lend themselves to critical appraisal in "Evidence-
based Medicine" terms easily but that in it should not detract from their
usefulness in everyday clinical practice. "Unconscious mind", "drive
theory" and other classic Freudian concepts belong to the set of
hypotheses whose validity might be difficult to prove, but nevertheless
whose utility is unquestionable. Such concepts provide an extremely useful
conceptual framework for clinicians to make sense of hugely complex and
nuanced human behaviour- both "healthy" and "pathological".
While helpful to all medical specialities, they are especially
relevant to mental health clinicians working with patients who do not
easily fit into established diagnostic categories or have significant
personality dysfunction.
Like with other medical theories, with greater knowledge and
technological advancements they can be suitably modified and refined to
the benefit of our patients. Just like any other hypothesis, Freudian
concept of "Unconscious mind" has its strength and limitations and by its
judicious use in the right context we would maximise its clinical utility.
I feel we as clinicians would be doing us and our patients a dis-
service if we remain totally ignorant about it or rigidly dismiss it
outright for not being easily compatible with classic "Evidence-based
Medicine".
Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is th...
Dear Editor
Our editorial was triggered by a PMJ paper showing that in a study carried
out in the US, 76% of first year doctors exhibited burnout. We quoted
other evidence that burnout may occur surprisingly early in careers and is
not necessarily related to seniority. We know that jobs which require
daily face to face interaction with people who are distressed or
challenging lead to high levels of burnout. Sadly it is those who are
most empathetic who become emotionally exhausted most quickly. We also
know that isolation, overwork, lack of sleep and lack of expertise all add
to the risk of burnout. New doctors should not have to cope with all of
those at once. There is evidence from the GMC's annual National Trainee
Survey (and before that the London-wide Point of View Survey) that over
the past 16 years the proportion of new doctors who feel stressed, bullied
or sleep-deprived has steadily reduced. We are not aware of any evidence
suggesting it has got worse, though stresses may well have been
transferred to those higher up the career ladder. Big problem is
dependence on doctors in training to deliver service. Not a problem as
such, but it is when service demands mean working under stress and without
colleagues and supervision. Unsupervised work provides experience but
cannot be considered as training. Working in teams, even if the membership
of the teams changes, mitigates against isolation and provides supervision
for the junior members.
Diana Hamilton-Fairley. Elisabeth Paice
We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent wit...
We agree that delirium is serious, and more structured instruments
are needed for providers of multiple specialties to detect delirium in
multiple health care settings. While we have no experience on the I-AGeD
in our emergency departments, we note that caregivers often are not
available at the time of emergency presentation. Also, we find veracity of
caregiver reports highly dependent on relationship and time spent with the
patient. Ideally, providers should have access to tools that use only
patient-level information in addition to tools that use caregiver
information for diagnosing delirium.
Dear Professor Jorwal,
In history of exercise physiology is often forgotten that Susruta of ancient India was the first physician to prescribe physical activity for health reasons. He promoted dietary changes and daily exercise of moderate intensity such as brisk walking to minimize the consequences of diabetes and obesity (1). Today, elderly people are very likely to benefit even from simple, full-body exercise...
The paper by Plum et al. (1) prompted us to verify how fourth year medical students performed in choosing the initial dose and route of administration of adrenaline in the treatment of adult anaphylaxis. The question was one of the 20 they had to answer by blackening the correct box (C for this specific question) to pass the Clinical Immunology (CI) exam. Many (approximately two-thirds) of the 192 students who resp...
Sir,
This article points out the well documented fact that increased physical activity has clear-cut protective effect from all cause mortality(1). Developing countries like India are also acknowledging such facts and are issuing guidelines for the same so as to promote health care of elderly even at primary health care level(2).
With development and prosperity the average individual age is increasin...
The increasing numbers of frail elderly patients certainly poses a challenge for all parts of the healthcare landscape within the UK and beyond. Whilst organisational change and modifications to where, when and how we deliver care is important this must be underpinned by appropriate education for doctors and allied healthcare professionals.
Much of this needs to be aimed at more junior staff, especially medical...
Predicting prognosis in this older group of patients is complex due to their highly variable health status, driven by their fundamentally different prognosis to younger patients. We have published two recent pieces on this theme, showing that firstly though there was an incremental reduction in the use of evidence-based therapies for ACS (acute coronary syndrome) with older age and that better survival was associated with...
When Professor Weller and her colleagues speak of members of the team being "on the same page"(1) no mention is made of the patient(or the patient's advocate)(2) being also on the identical page. To facilitate the inclusion of the patient in the team I have proposed the use of an abbreviated patient-held health record which essentially documents the problem list and the corresponding drug list, and this should be updated...
I would like to thank the author on a thoughtful reflection on the "unconscious mind" and would like to comment on its relevance in modern medicine especially psychiatry and allied fields.
Understandably concepts like the "drive theory" or "defence mechanisms" do not lend themselves to critical appraisal in "Evidence- based Medicine" terms easily but that in it should not detract from their usefulness in every...
Dear Editor Our editorial was triggered by a PMJ paper showing that in a study carried out in the US, 76% of first year doctors exhibited burnout. We quoted other evidence that burnout may occur surprisingly early in careers and is not necessarily related to seniority. We know that jobs which require daily face to face interaction with people who are distressed or challenging lead to high levels of burnout. Sadly it is th...
We agree that delirium is serious, and more structured instruments are needed for providers of multiple specialties to detect delirium in multiple health care settings. While we have no experience on the I-AGeD in our emergency departments, we note that caregivers often are not available at the time of emergency presentation. Also, we find veracity of caregiver reports highly dependent on relationship and time spent wit...
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